ADDRESSING MDR TB IN THE CONTEXT OF HIV: Lessons from Lesotho. Dr Hind Satti PIH Lesotho Director MDR-TB program

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1 ADDRESSING MDR TB IN THE CONTEXT OF HIV: Lessons from Lesotho Dr Hind Satti PIH Lesotho Director MDR-TB program

2 TB Situation in Lesotho 12,275 TB new cases notified in 2007 Estimated prevalence of 544 per 100,000 population Estimated annual incidence for all cases is 691 per 100,000 population Estimated incidence of Sputum smear positive cases is 281 per 100,000 population 75% of new TB cases among age-group years Estimated all TB deaths is 107/100,000 annually The HIV prevalence rate in Lesotho stands at 23.2% in % of TB cases are HIV positive (WHO 2007), 80% (NTP 2008)

3 The Social Context of Drug-Resistant TB Drug-resistant TB patients vulnerable population Disease has socioeconomic causes and consequences Addressing adherence is key to treatment success Community-based models of care ideal for addressing these issues

4 Socioeconomic Causes and Consequences of TB Poor housing Malnutrition Overcrowding Poverty Poor infrastructure

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6 WHAT ARE THE BARRIERS TO CARE? Diagnosis of TB and MDR-TB in patients with HIV Having facilities to care for very sick patients Infection control in a high HIV setting Having a mechanism to deliver MDR-TB care (± HIV treatment) in urban and rural areas Shortage of trained human resource Extreme poverty (the social and economic devastation) Migration of workers to South Africa to work in the mines

7 Diagnosis: Built laboratory capacity for mycobacterial culture and drug susceptibility testing

8 Drugs: quality-assured drug supply at an affordable price

9 Facility to care for the very sick: refurbishment of an existing hospital to create an MDR-TB/HIV center of excellence

10 Inpatient Care Very sick patients Bedridden Severely wasted Severe side effects Severe hypokalemia Acute renal failure due to injectable and ARTs. Severe OIs Cryptococcal meningitis CMV retinitis

11 Infection control in a high HIV setting: masks for all staff and stateof-the art ventilation in facilities Occupational policy.

12 Adherence Adherence crucial in successful treatment of drug-resistant TB Barriers to adherence are socioeconomic and must be addressed Adverse effects also contribute to poor adherence

13 Accompaniment (including Directly Observed Therapy (DOT)) is the basis for successful treatment Accompaniment allows programs to ensure that patient will complete an adequate course of treatment. Accompaniment facilitates the management of side effects and the prevention of some of them. Through the process of Accompaniment, medical worker can predict and prevent the episodes of non-adherence When patients receive all their medications under observation they become non-infectious sooner, and this helps reduce transmission

14 Community-Based Care Twice-daily DOT Injections Psychosocial support Screening household contacts Accompaniment to clinical visits Offer HTC, FP, chronic disease screening and HCG at home.

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17 Poverty: assistance with food, housing, fuel and transportation

18 Facts about the program Over 200 patients enrolled on treatment. 30% were from mining companies. 80% MDR-TB/HIV co-infection. NO DEFULTERS. All co-infected patients were started on ARVs regardless of their CD4 count. Decentralized to all districts hospitals. Over 2000 community health workers were trained. All children on treatment are orphans: lost both parents or one of them due to MDR TB/HIV.

19 Conclusion The program trained over 200 health workers from all districts. We offer international training for other countries on MDR TB/HIV and infection control (3 groups from 3African countries were trained).

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